Elderly Housing: Federal Housing Programs and Supportive Services
(16-JUN-05, GAO-05-795T).					 
                                                                 
According to a congressionally established bipartisan commission,
decreased investment in affordable housing and an elderly	 
population that is projected to grow from about 12 percent of the
population in 2002 to 20 percent by 2030 are likely to increase  
the number of elderly who must spend large portions of their	 
incomes on housing. Moreover, according to this commission, more 
than one-third of the elderly tenants of government-subsidized	 
housing require assistance with some type of activity of daily	 
living, such as making a meal or getting in and out of bed. This 
testimony, which is based on a report issued in February 2005,	 
discusses (1) the federal housing assistance programs requiring  
that supportive services be made available to elderly residents, 
(2) other Department of Housing and Urban Development (HUD)	 
programs that assist the elderly in obtaining supportive	 
services, and (3) private partnerships and federal health care	 
programs that may provide supportive services to elderly	 
beneficiaries of federal housing assistance.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-795T					        
    ACCNO:   A26798						        
  TITLE:     Elderly Housing: Federal Housing Programs and Supportive 
Services							 
     DATE:   06/16/2005 
  SUBJECT:   Elder care 					 
	     Elderly persons					 
	     Housing						 
	     Housing programs					 
	     Interagency relations				 
	     Low income housing 				 
	     Mortgage programs					 
	     Mortgage protection insurance			 
	     Program evaluation 				 
	     Public assistance programs 			 
	     Public housing					 
	     Rural housing programs				 
	     HUD Assisted Living Conversion Program		 
	     HUD Congregate Housing Services Program		 
	     HUD Neighborhood Networks Program			 
	     HUD ROSS Grant Program				 
	     HUD Section 202 Elderly Housing Program		 
	     HUD Section 232 Mortgage Insurance 		 
	     Program						 
                                                                 
	     HUD Service Coordinator Program			 
	     USDA Section 515 Program				 

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GAO-05-795T

United States Government Accountability Office

GAO Testimony

Before the Senate Committee on Banking,

Housing, and Urban Affairs

For Release on Delivery

Expected at 10:00 a.m. EDT ELDERLY HOUSING

Thursday, June 16, 2005

                Federal Housing Programs and Supportive Services

Statement of David G. Wood, Director Financial Markets and Community Investment

GAO-05-795T

[IMG]

June 16, 2005

ELDERLY HOUSING

Federal Housing Programs and Supportive Services

  What GAO Found

Of the 23 housing assistance programs GAO reviewed, only 4 require the
owners of participating properties to ensure that services such as meals
or transportation are available to residents. Three are HUD programs: the
Section 202 Supportive Housing for the Elderly Program, which subsidizes
multifamily properties for elderly households with very low incomes; the
Assisted Living Conversion Program, which subsidizes the conversion of
HUD-subsidized multifamily properties into assisted living facilities; and
the Section 232 Mortgage Insurance Program, which insures mortgages for
licensed facilities that provide varying levels of skilled care and
services. USDA's Section 515 Rural Rental Housing Loan program, which
makes loans for the construction and rehabilitation of rural multifamily
properties, has a Congregate Housing Services subprogram that requires the
provision of supportive services.

HUD administers four programs that can be used with various housing
programs to help the elderly with supportive services:

o  	Congregate Housing Services Program, which provides grants for the
delivery of meals and nonmedical supportive services to elderly and
disabled residents of public and multifamily housing;

o  	Neighborhood Networks Program, which encourages the development of
computer centers in HUD-supported housing;

o  	Resident Opportunities and Self Sufficiency (ROSS) Program, which
links public housing residents with services; and

o  	Service Coordinator Program, which funds coordinators who help elderly
residents access services such as transportation and health care at some
multifamily properties.

Supportive services may also be available to elderly residents of
subsidized housing through partnerships between individual properties and
local organizations and through Department of Health and Human Services
(HHS) programs. For example, HHS's Public Housing Primary Care Program
provides public housing residents with access to affordable primary and
preventive health care through clinics that are located in or near the
properties. GAO did not obtain data on the extent to which such services
are made available.

                 United States Government Accountability Office

Mr. Chairman and Members of the Committee:

I appreciate the opportunity to be here today as the Committee considers
ways to promote coordination among federal programs that provide housing
and other services to the elderly. According to the report of the
congressionally established Commission on Affordable Housing and Health
Facility Needs for Seniors in the 21st Century, decreased investment in
affordable housing and a burgeoning elderly population that is projected
to grow from about 12 percent of the population in 2002 to 20 percent by
2030 are likely to increase the number of elderly who must spend large
portions of their incomes on housing.1 Moreover, according to the
Commission, about a third of the elderly tenants of governmentsubsidized
housing required assistance with some type of activity of daily living,
such as preparing meals or getting in and out of bed or a chair.

My statement is based largely on our recent report to the Senate's Special
Committee on Aging, which requested that we identify federal programs that
provide housing assistance to the elderly and the extent to which
supportive services, such as meals and transportation, were affiliated
with these programs.2 Beginning in the 1930s, a number of federal housing
programs have subsidized the construction of housing for the poor,
provided rental assistance to tenants in existing privately owned housing,
and insured mortgages for both single-and multifamily properties. Today,
the Department of Housing and Urban Development (HUD) administers the
majority of federal housing assistance programs in urban areas, and the
U.S. Department of Agriculture's (USDA) Rural Housing Service (RHS)
implements housing programs in rural areas. Among the programs they
administer are a number that either target the elderly specifically or
provide benefits for which the elderly are eligible. My statement
discusses (1) housing assistance programs that serve the elderly and
require that supportive services be made available to elderly residents,
(2) other HUD programs that can be used in conjunction with housing
programs to assist the elderly in obtaining supportive services, and (3)
private partnerships

1Commission on Affordable Housing and Health Facility Needs for Seniors in
the 21st Century, A Quiet Crisis in America (Washington, D.C.: June 30,
2002). Available at http://www.seniorscommission.gov.

2GAO, Elderly Housing: Federal Housing Programs That Offer Assistance for
the Elderly, GAO-05-174 (Washington, D.C.: February 14, 2005). For this
report, we defined elderly as individuals aged 62 and older.

and federal health care programs that may provide some services in
conjunction with federally assisted housing.

In preparing this information, we consulted with HUD and USDA officials to
identify housing assistance programs that benefit the elderly. We reviewed
laws and regulations to determine which of the housing assistance programs
within our scope were required to ensure that supportive services were
available. We identified programs providing supportive services that could
be used with various housing assistance programs, whether or not such
services were required. We reviewed literature and descriptions of housing
assistance programs and interviewed administrators of the housing
assistance programs within our scope, as well as representatives of
advocacy organizations and professional associations interested in elderly
housing issues and supportive services. We obtained descriptions of the
supportive services programs by interviewing and obtaining documentation
from officials from HUD, USDA, and the Department of Health and Human
Services (HHS). We performed our work in Baltimore, Maryland; Greensboro
and Raleigh, North Carolina; Columbus, Ohio; Oklahoma City and Stillwater,
Oklahoma, and Washington, D.C., between December 2003 and December 2004 in
accordance with generally accepted government auditing standards.

In brief:

o  	Of 23 federal housing assistance programs that we reviewed, only 4
required property owners to ensure that services such as meals or
transportation were available to their residents. Three are HUD programs:
the Section 202 Supportive Housing for the Elderly Program, which
subsidizes the development and operating costs of multifamily properties
for elderly households with very low incomes; Assisted Living Conversion
Program, which subsidizes the conversion of HUD-subsidized multifamily
properties into assisted living facilities; and Section 232 Mortgage
Insurance Program, which insures mortgages for licensed facilities that
provide varying levels of skilled care and services. In addition, USDA's
Section 515 Rural Rental Housing Loan program, which makes loans for the
construction and rehabilitation of rural multifamily properties, has a
Congregate Housing Services subprogram that requires the provision of
supportive services.

o  	HUD administers four service-related programs that can be used in
conjunction with various housing programs to assist the elderly in
obtaining supportive services: the Congregate Housing Services Program,

which provides meals and other services in public and multifamily housing
properties; the Neighborhood Networks Program, which provides resources
for establishing computer networks at these sites; and the Resident
Opportunities and Self Sufficiency (ROSS) and Service Coordinator
programs, which link residents with services in the community.

o  	Supportive services may also be available to elderly residents of
subsidized housing through partnerships between individual properties and
local organizations and through programs provided by HHS. For example,
HHS's Public Housing Primary Care Program provides public housing
residents with access to affordable comprehensive primary and preventive
health care through clinics that are located either in or near public
housing properties.

                                   Background

Beginning in the 1930s, a number of federal housing programs have provided
assistance to low-income renters and homeowners, including rent subsidies,
mortgage insurance, and loans and grants for the purchase or repair of
homes. Housing developments can be assisted by multiple programs. For
example, a loan or mortgage on a multifamily property may be insured
through a HUD or USDA program, and the property may have tenants that
receive rental assistance from these agencies. In our earlier report, we
identified a total of 23 federal housing programs that target or have
special features for the elderly.3 Of these programs, 2 are intended for
the elderly only, 3 target the elderly and disabled, and another 18 have
special features for the elderly, such as income adjustments that lower
elderly households' rental payments. Appendix I lists these housing
assistance programs.

In general, both HUD and USDA programs target families at lower income
levels. HUD programs target families with incomes that are extremely low
(no more than 30 percent of an area's median), very low (no more than 50
percent of an area's median), and low (no more than 80 percent of an
area's median). USDA programs also target families with incomes that are
very low and low. In addition, some USDA programs target families with
moderate incomes (no more than 115 percent of an area's median). However,
these programs do not reach all needy households, and waiting

3GAO-05-174.

lists for many types of subsidized housing, including housing for the
elderly, are often long.

HUD has specific goals for increasing housing opportunities for the
elderly, including one goal specifically related to supportive services.
As outlined in its fiscal year 2004 Annual Performance Plan, these goals
include (1) increasing the availability of affordable housing for the
elderly, (2) increasing the number of assisted-living units, (3)
increasing the number of elderly households living in privately owned,
federally assisted multifamily housing served by a service coordinator,
and (4) increasing elderly families' satisfaction with their Section 202
units. USDA does not have specific goals related to the elderly in its
fiscal year 2004 Annual Performance Plan.

As GAO has previously reported, virtually all the results that the federal
government strives to achieve require the concerted and coordinated
efforts of two or more agencies. This shared responsibility is an
outgrowth of several factors, including the piecemeal evolution of federal
programs and service delivery efforts.4 Achieving results on public
problems, such as the potentially large service needs of a growing elderly
population, increasingly calls for effective interagency coordination.
However, our work has shown that a number of barriers inhibit coordination
among agencies. For example:

o  	In reporting on the coordination of programs for the homeless, we
noted that the federal government's system for providing assistance to
lowincome people is highly fragmented. Each federal assistance program
usually has its own eligibility criteria, application, documentation
requirements, and time frames; moreover, applicants may need to travel to
many locations and interact with many caseworkers to receive assistance.5

o  	A review of federally assisted transportation services for
"transportationdisadvantaged" seniors (who are more likely to have
difficulty accessing transportation due to physical ailments) found that 5
federal agencies administer 15 programs. Service providers told GAO that
certain characteristics of federal programs, such as what the providers
view as

4GAO, Managing for Results: Barriers to Interagency Coordination,
GAO/GGD-00-106 (Washington, D.C.: March 29, 2000).

5GAO, Homelessness: Improving Program Coordination and Client Access to
Programs, GAO-02-485T (Washington, D.C.: March 6, 2002).

Four Housing Assistance Programs Require That Supportive Services Be Made
Available to

o

  Elderly Residents

burdensome reporting requirements and limited program guidance, can impede
the implementation of practices that enhance senior mobility.6

o  	More generally, we have noted the range of barriers to coordination
that agencies often face, including missions that are not mutually
reinforcing or that may even conflict; concerns about protecting
jurisdiction over missions and control over resources; and incompatible
procedures, processes, data, and computer systems.7

Generally, HUD and USDA's housing assistance programs are not required to
provide supportive services to the elderly. Of the 23 housing assistance
programs that target or include the elderly among potential beneficiaries,
only 4 require the owners of properties developed under the programs to
ensure that supportive services are available. Appendix II provides
summaries of the four programs, which include:

HUD's Section 202 program, which subsidizes the development and operating
costs of multifamily properties for elderly households with very low
incomes. It is the only federal housing program that targets all of its
rental units to very-low-income elderly households. Applicants for Section
202 funding must demonstrate that services will be available at the
development or in the community where new construction is proposed.

o  	HUD's Assisted Living Conversion Program, which provides private
nonprofit owners of eligible properties with grants to convert some or all
of their units into assisted living facilities for the frail elderly. The
reconfigured facilities must include enough community space to accommodate
a central kitchen or dining area, lounges, and recreation and other
multiple-use areas. The facilities must provide supportive services such
as personal care, transportation, meals, housekeeping, and laundry.

o  	HUD's Section 232 Mortgage Insurance Program, which provides mortgage
insurance for the construction or substantial rehabilitation of nursing
homes (facilities that provide skilled nursing care and have 20 or more
beds); intermediate care facilities (those that provide minimum but
continuous care and have 20 or more beds); board and care homes

6GAO, Transportation-Disadvantaged Seniors: Efforts to Enhance Senior
Mobility Could Benefit from Additional Guidance and Information,
GAO-04-971 (Washington, D.C.: August 30, 2004).

7GAO/GGD-00-106.

(facilities that provide room, board, and continuous protective oversight
and have at least 5 accommodations); and assisted living facilities (those
with 5 or more units designed for frail elderly persons who need
assistance with at least 3 activities of daily living). All insured
facilities must provide supportive services, but these services vary
according to the type of facility.

o  	USDA's Section 515 Program, which provides loans to construct or to
purchase and substantially rehabilitate multifamily rental or cooperative
housing and recreational facilities in rural communities. Tenants eligible
to live in program properties may also receive rental assistance through
HUD or USDA programs. The Congregate Housing subprogram funds the
development of assisted, group living environments that must provide
meals, transportation, housekeeping, personal services, and recreational
and social activities.

Generally, HUD and USDA do not provide funding for the services required
under these housing programs.8 The property owners typically obtain other
funds, either from federal programs, local charities, and civic groups to
provide supportive services or must ensure that appropriate services are
available in the community.

Other HUD Programs 	HUD administers four service-related programs that can
be used in conjunction with subsidized housing programs: two programs that
provide

Can Assist the Elderly supportive services to residents of public and
multifamily properties

in Obtaining developed under HUD programs, and two that link residents to
supportive services. None of these programs are targeted exclusively to
the elderly,Supportive Services but they either can be used in properties
designated for the elderly or offer funding specifically for services for
the elderly.

o  	The Congregate Housing Services Program provides grants for the
delivery of meals and nonmedical supportive services to elderly and
disabled residents of public and multifamily housing, including USDA's
Section 515 housing. While HUD provides up to 40 percent of the cost of
supportive services, grantees must pay at least 50 percent of the costs,
and program

8Under the Section 202 capital advance program, if a sponsor indicates
that at least 25 percent of tenants are expected to be frail elderly, HUD
allows the sponsor to use funds from the project rental assistance
contract to pay for a service coordinator. A portion of the funds (up to
$15 per month per unit) may also be used to cover some of the cost of
supportive services.

participants pay fees to cover at least 10 percent.9 Like the
Elderly/Disabled Services Coordinator Program under ROSS, the Congregate
Housing Services Program has provided no new grants since 1995, but
Congress has provided funds to extend expiring grants on an annual basis.

o  	The Neighborhood Networks program encourages property owners,
managers, and residents of HUD-insured and -assisted housing to develop
computer centers. Although computer accessibility is not a traditional
supportive service for the elderly, a senior HUD official noted that
having computers available enhances elderly residents' quality of life.
HUD does not fund each center's planned costs but encourages property
owners to seek cash grants, in-kind support, and donations from sources
such as state and local governments, educational institutions, private
foundations, and corporations.10

o  	The ROSS grant program links public housing residents with appropriate
services. This program differs from the Service Coordinator Program in
that it is designed specifically for public housing residents. The ROSS
program has five funding categories, including the Resident Service
Delivery Models for the Elderly and Persons with Disabilities (Resident
Services) and the Elderly/Disabled Service Coordinator Program. Resident
Services funds can be used to hire a project coordinator; assess
residents' needs for supportive services and link residents to federal,
state, and local assistance programs; provide wellness programs; and
coordinate and set up meal and transportation services. The
Elderly/Disabled Service Coordinator Program has not provided new grants
since 1995 but still services existing grants.11

o  	The Service Coordinator Program provides funding for managers of
multifamily properties designated for the elderly and disabled to hire
coordinators to assist residents in obtaining supportive services from
community agencies. These services, which may include personal assistance,
transportation, counseling, meal delivery, and health care, are intended
to help the elderly live independently and to prevent premature and
inappropriate institutionalization. Service coordinators can be funded

9Fees cannot exceed 20 percent of an individual's adjusted income.

10Grant funding for Neighborhood Networks centers can also be provided to
public housing authorities through HUD's Office of Public and Indian
Housing.

11In fiscal year 2004, new grants for the program were funded through the
Public Housing Operating Fund.

  Private Partnerships and Federal Health Care Programs May Provide Some
  Supportive Services

through competitive grant funds, residual receipts (excess income from a
property), or rent increases. According to HUD's fiscal year 2003
Performance and Accountability Report, service coordinators were serving
more than 111,000 units in elderly properties.

Elderly residents of public and federally subsidized multifamily housing
can also receive supportive services through partnerships between property
owners and local organizations and through programs provided by HHS. For
example, property owners can establish relationships with local nonprofit
organizations, including churches, to ensure that residents have access to
the services that they need. At their discretion, property owners may
establish relationships that give the elderly access to meals,
transportation, and housekeeping and personal care services. Although GAO
did not obtain data on the extent to which such services are made
available at all public and federally subsidized multifamily housing, in
site visits to HUD and USDA multifamily properties, we found several
examples of such partnerships:

o  	In Greensboro, North Carolina, Dolan Manor-a Section 202 housing
development-has established a relationship with a volunteer group from a
local church. The volunteer group provides a variety of services such as
transportation for the residents.

o  	In Plain City, Ohio, residents of a Section 515 property called
Pleasant Valley Garden receive meals five times a week in the community's
senior center (a $2 donation is suggested). A local hospital donates the
food and a nursing home facility prepares it. Volunteers, including
residents, serve the meals. The senior center uses the funds collected
from the lunch for its activities. In addition, local grocery stores
donate bread products to the senior center daily. The United Way provides
most of the funding for the senior center.

o  	In Guthrie, Oklahoma, Guthrie Properties-also a Section 515 property-
has established a relationship with the local Area Agency on Aging. The
agency assists residents of Guthrie Properties in obtaining a variety of
services, including meals and transportation to a senior center.

Some elderly residents of public and federally subsidized housing may also
obtain health-related services through programs run by HHS. For example,
HHS's Public Housing Primary Care Program provides public housing
residents with access to affordable comprehensive primary and preventive
health care through clinics that are located either within public housing

properties or in immediately accessible locations. The program awards
grants to public and nonprofit private entities to establish the clinics.
The organizations must work with public housing authorities to obtain the
physical space for the clinics and to establish relationships with
residents. Currently, there are 35 grantees, 3 of which are in rural
areas. According to a program administrator, although clinics are not
specifically geared toward public housing designated for the elderly, they
can be established at such properties.

Elderly residents of federally subsidized housing may also be eligible for
the Medicaid Home and Community-Based Services (HCBS) Waiver Program,
which is administered by HHS's Centers for Medicare and Medicaid Services.
Through this waiver program, individuals eligible for Medicaid can receive
needed health care without having to live in an institutional setting.12
HUD has identified these waivers as an innovative model for assisting the
frail elderly in public housing.

In addition, eligible elderly residents of federally subsidized housing
may receive health care through the Program of All-Inclusive Care for the
Elderly (PACE), which is also administered by the Centers for Medicare and
Medicaid Services.13 Like the HCBS waiver program, this program enables
eligible elderly individuals to obtain needed services without having to
live in an institutional setting. The program integrates Medicare and
Medicaid financing to provide comprehensive, coordinated care to older
adults eligible for nursing homes. Figure 1 provides information on the
housing assistance programs that can use federally funded supportive
services programs that assist the elderly.

12In order to be eligible for health care services through the HCBS waiver
program, individuals must meet a "level of care" requirement that varies
by state but that typically is measured by standards of care for either
hospitals, nursing facilities, or intermediate care facilities for persons
with mental retardation.

13PACE participants must be at least 55 years old, live in the service
area, and be certified as eligible for nursing home care by the
appropriate state agency.

Figure 1: Housing Assistance Programs That Can Use Federally Funded
Supportive Services Programs

Notes: Congregate Housing Services Program grants cannot be awarded to
Section 221(d)(4) housing. Information on the extent to which elderly
residents actually utilized these supportive services was generally not
available at the federal level.

Mr. Chairman, this concludes my prepared statement. I would be happy to
answer any questions at this time.

Contacts and	For further information on this testimony, please contact
David G. Wood at (202) 512-8678. Individuals making key contributions to
this testimony

Acknowledgements 	included Emily Chalmers, Natasha Ewing, Alison Martin,
John McGrail, Marc Molino, Lisa Moore, John Mingus, Paul Schmidt, and
Julianne Stephens.

Appendix I: Housing Programs Targeted to or with Special Features for the
Elderly

S Single family M Multifamily P Public housing R Rental assistance The
elderly are the only beneficiaries
Assisted living facilities and properties make supportive services
available
Properties can be designated for occupancy by the elderly
The elderly receive income adjustments when determining program
eligibility or rent
Sources: GAO analysis of authorizing legislation, program regulations,
program handbooks, and other HUD and USDA documents.

aBefore fiscal year 1992, the Section 202 program also supported the
development of housing for the disabled.

bInactive programs no longer provide assistance or insurance to new
properties, but existing properties continue to operate under the
programs.

cThe Section 515 program's Congregate Housing subprogram requires
properties to provide supportive services.

Appendix II: Housing Assistance Programs That Require That Supportive Services
Be Made Available to Elderly Residents

      Figure 3: Section 202 Supportive Housing for the Elderly Description

Source: GAO analysis of program information and HUD data.

aElderly units are designated for occupancy by the elderly. Elderly or
nonelderly households may occupy nonelderly units. Elderly households had
an elderly head, cohead, or spouse, regardless of whether the unit was
designated for the elderly. The number of households was less than the
number of units because HUD only had occupancy data on households
receiving project-based rental assistance.

Figure 4: Assisted Living Conversion Program Description

Source: GAO analysis of program information and HUD data.

aAssisted living facilities are designed to accommodate the frail elderly
and persons with disabilities who can live independently but need
assistance with activities of daily living. These facilities must provide
supportive services such as personal care, transportation, meals,
housekeeping, and laundry.

Figure 5: Section 232 and 232/223(f) Mortgage Insurance Description

Source: GAO analysis of program information and HUD data.

aCombination refers to properties that featured multiple facility types.
Unknown refers to properties where data on facility type were unavailable.
HUD did not have sufficient data to determine the total number of beds or
units in all properties. Approximately 16,972 units were designated for
the elderly.

Figure 6: Section 515 Rural Rental Housing Loan Description

Source: GAO analysis of program information and USDA data.

aElderly units are designated for occupancy by the elderly or disabled.
Elderly or nonelderly households may occupy nonelderly units. Elderly
households had an elderly head, cohead, or spouse, regardless of whether
the unit was designated for the elderly.

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